Global Health

Many people are deeply skeptical of foreign aid, believing that these monies often wind up in the pockets of corrupt leaders or never make it down the chain of bureaucracy to the people who really need it. But a new Stanford analysis of both government and private aid programs shows that health aid has been extremely effective not only in extending the lives of people in developing countries but also saving the lives of children under age 5.

Lead researcher Eran Bendavid, MD, said foreign aid programs had their biggest impact between 2000 and 2010, when investments in health reached their peak. During that time, the U.S. government launched its hugely successful initiative, the President’s Emergency Plan for AIDS Relief (PEPFAR), while other private groups, such as the Gates Foundation, stepped up investments in health as well.

During that time, low-income countries receiving aid saw a dramatic decline – between 26 and 34 percent – in the number of children who died before their 5th birthday. With just a 4 percent increase in aid, or $1 billion, foreign aid could continue to have a major impact on child mortality, Bendavid said.

“If health aid continues to be as effective as it has been, we estimate there will be 364,800 fewer deaths in children under 5,” Bendavid said. “We are talking about $1 billion, which is a relatively small commitment for developed countries.”

He said many people may find the results surprising. “But for me, it fits with other evidence of the incredible success of public health promotion in developing countries,” he said. For instance, he did a study in 2012 which found that more than 740,000 lives were saved between 2004 and 2008 in nine countries as a result of the PEPFAR program. Other technologies, such as diphtheria, tetanus, measles and polio vaccines for children and insecticide-treated bed nets to prevent malaria, all have contributed to better health among adults and children in low-income countries.

He and colleague Jay Bhattacharya, MD, PhD, also found that aid programs had a lasting impact. The signs of aid’s impact on child mortality were measurable for three years after aid was distributed, while the link between aid and longer life expectancy was detectable five years after aid was made available, the researchers reported.

Previously: Stanford study: South Africa could save millions of lives through HIV prevention and PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds
Photo by Karen Ande

Simply washing your hands can reduce the reduce respiratory illnesses, such as colds, in the general public by 21 percent, cut the number of people who get sick with diarrhea by 31 percent and lower diarrheal illness in people with weakened immune systems by 58 percent, according to data from the Centers for Disease Control and Prevention.

Despite these compelling facts, and many years of global awareness campaigns, hand-cleaning rates remain far below full compliance — particularly in low-income, developing world settings. But using video surveillance to observe hygiene practices can offers insights that may help improve design, monitoring and evaluation of hand-washing campaigns, according to a new Stanford study.

For the study, researchers installed video cameras at the washing stations outside latrines of four public schools in the Kibera slum of Nairobi, Kenya. Teachers were informed in advance and parents and administrators granted their permission for the experiment. Their findings were highlighted in a Stanford News article published yesterday:

• Both video observation and in-person observation demonstrated longer hand cleaning times for hand washing with soap as compared to rubbing with sanitizer.
• Students at schools equipped with soap and water, instead of sanitizer, were 1.3 times more likely to wash their hands during simultaneous video surveillance and in-person observation when compared with periods of in-person observation alone.
• Overall, when students were alone at a hand-cleaning station, hand cleaning rates averaged 48 percent, compared to 71 percent when at least one other student was present.

Based on their findings, study authors recommended the following approaches for boosting hand washing:

• Placement of hand cleaning materials in public locations
• Scheduling specific times for bathroom breaks between classes
• Designating specific students to be hand hygiene “champions”
• Formation of student clubs to demonstrate and promote hand hygiene to classmates

Previously: Examining the effectiveness of hand sanitizers, Survey outlines barriers to handwashing in schools, Examining hand hygiene in the emergency department, Good advice from Washyourhandsington and Hey, health workers: Washing your hands is good for your patients
Photo by Amy Pickering

Adolescent girls in the slums of Nairobi, Kenya, are frequent targets of sexual harassment and assault: Nearly one in five of them is raped each year. When these crimes are perpetrated against Nairobi’s teen girls, they’re often expected to react with shame and silence.

But a small non-governmental organization, No Means No Worldwide, has a strategy to change that. The co-founders, Jake Sinclair, MD, and Lee Paiva, an American husband-and-wife team, developed a curriculum of empowerment training to teach girls that it’s OK to say “no” to unwanted sexual advances. The training also gives girls specific verbal and physical skills to defend themselves, as well as information about where to go for help after a rape or other sexual assault.

The results are impressive. Stanford researchers who work with Sinclair and Paiva report today in Pediatrics that the empowerment training cut annual rates of rape by more than a third. Among the group of 1,978 girls trained during the study, more than half used their new knowledge to fend off attempted rape, and 65 percent stopped instances of harassment, halting hundreds of incidents.

From our press release about the research:

“Clearly, girls should never be placed in these situations in the first place,” said Clea Sarnquist, DrPH, the study’s lead author and a senior research scholar in pediatrics at Stanford. Changing males’ attitudes and behavior about assault is an important area for the team’s current and future work, she said. “But with such a high prevalence of rape, these girls need something to protect them now. By giving them the tools to speak up and the knowledge that ‘I have domain over my own body,’ we’re giving them the opportunity to protect themselves.”

The video above, one of a series of testimonials that No Means No Worldwide has collected from Nairobi girls, shows the power of that sense of domain over one’s body. In the video, a schoolgirl named Catherine tells how she stopped a male student from harassing her. When the video begins, it’s impossible not to notice how young and vulnerable she seems. But then she recounts how, when this boy followed her and demanded sex, she remembered her self-defense classes.

“I stood and maintained eye contact,” she says in the video. “I warned him that day and told him he should never in his life dare follow me.”

As she says the words, her demeanor transforms: She draws herself up straight, looks directly in the camera, and raises her index finger in a gesture of commanding attention.

Maryanne Wangui, a young Kenyan woman who recorded many of the testimonials, said something to me that resonates with Catherine’s account and sticks in my mind: “If you give girls the right skills, they know what to do. It doesn’t matter the age of the girl or the size of the girl; they’re all powerful inside.”

Previously: Self-defense training reduces rapes in Kenya
Video courtesy of No Means No Worldwide

Médecins Sans Frontières and other international aid organizations are furiously working to contain an outbreak of Ebola in Guinea and nearby African countries. Latest reports estimate that the virus has infected 157 people and killed 101 in Guinea alone.

A New Scientist story published today explains how health workers from Médecins Sans Frontières were initially at a disadvantage when they arrived in Guinea to combat the deadly virus because they only had topographic charts to use in pinpointing the source of the disease. Desperately in need of maps that would be useful in understanding population distribution, the organization turned to Humanitarian OpenStreetMap Team, which coordinated a crowdsourcing effort to produce the first digital map of Guéckédou, a city of around 250,000 people in southern Guinea. Hal Hodson writes:

As of 31 March, online maps of Guéckédou were virtually non-existent, says Sylvie de Laborderie of cartONG, a mapping NGO that is working with MSF to coordinate the effort with HOT. “The map showed two roads maybe – nothing, nothing.”

Within 12 hours of contacting the online group, Guéckédou’s digital maps had exploded into life. Nearly 200 volunteers from around the world added 100,000 buildings based on satellite imagery of the area, including other nearby population centres. “It was amazing, incredible. I have no words to describe it. In less than 20 hours they mapped three cities,” says de Laborderie.

Mathieu Soupart, who leads technical support for MSF operations, says his organisation started using the maps right away to pinpoint where infected people were coming from and work out how the virus, which had killed 95 people in Guinea when New Scientist went to press, is spreading. “Having very detailed maps with most of the buildings is very important, especially when working door to door, house by house,” he says. The maps also let MSF chase down rumours of infection in surrounding hamlets, allowing them to find their way through unfamiliar terrain.

Previously: Using crowdsourcing to diagnose malaria and On crowdsourced relief efforts in Haiti

When Stanford bioengineer Manu Prakash, PhD, and his students set out to solve a challenging global health problem, the first order of business is to have fun.

“We’re a curiosity-driven lab,” says Prakash, as he sits in his office overflowing with toys, gadgets, seashells and insect exoskeletons.

In the last month, Prakash introduced two new cool science tools — a 50-cent paper microscope and a $5 programmable kid’s chemistry set. The response from fellow science lovers, compiled on this Storify page, has been amazing.

Already, 10,000 kids, teachers, health workers and small thinkers from around the globe have signed up to receive build-your-own-microscope kits. Thousands more have sent us e-mails describing the creative ways they’d use a microscope that they could carry around in their back pockets.

For the love of science, here are a few of these inspirational e-mails:

I would love to have one. I’m only in 6th grade but I love science. I hope to visit the moon one day. — Raul

I am an electrical engineer from Kenya and have never used a microscope in all my life. But what I would really like to do is to avail the foldscope to students in a primary school that I am involved in mentoring. This apart from hopefully inspiring them in the wonders of science, would enable the students see the structure of the mosquito proboscis, a malaria-spreading agent in this part of the world. I would also like to look at the roots of mangrove trees and see the structure that enables them to keep sea water salts out. — Macharia Wanyoike

This is brilliant! I am in science and nanotechnology education and my wish is for South African rural children, Namibia, Zimbabwe, Botswana to all have these microscopes! It will be amazing. — Professor Sanette Brits, University of Limpopo, South Africa

I am studying how magnetic fields at different frequencies affect water bears. They are very difficult to find and it would be great if I had a tool to help me find them that is  portable while searching for them. I have digital motic microscope phase contrast and darkfield microscopes but nothing portable. — Edward W. Verner (Water bear shown to the left.)

I could use it to check if patients have scabies. Or if I were visiting remote monasteries in the Himalayas where they have outbreaks. I’d definitely pack it. For myself I’d use it on nature walks. GREAT ACCOMPLISHMENT for mankind. Congratulations. — Linda Laueeano, RN

Hi! I am a high school student from South Korea. While I was searching for interesting project, I saw your video. It was very amazing and I can’t believe that only one dollar can save hundreds and thousands people who were suffering from malaria and other diseases that can be found by your “foldscope”. I really love to study about your project and I had already read your thesis. Truly, it was hard to understand everything, but I really tried hard and I discussed this issue for more than a week with my science club. We are group of 10 people and we are eager to do this project. Also I really appreciate you to do this wonderful thing for poor kids in many other countries. Thanks. — Joung Yeon Park

I am assisting a K-12 community school with creating a STEAM Innovation Knowledge HUB, as they are trying to move their Common Core Curriculum into a STEM to STEAM driven program. It would be great to receive several Foldscopes or be able to purchase. Please contact me ASAP. Congratulations on a great new support product and great innovation. Thank you, smile. — Dr. Dion N. Johnson, Wayne State University

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Over the past few weeks my colleague Kris Newby has been writing about the Foldscope, the 50-cent microscope developed by bioengineer Manu Prakash, PhD. Today Prakash is announcing another device that will bring high tech science to the developing world – and to kids.

The device won a contest from the Gordon and Betty Moore Foundation and the Society for Science & the Public to “Reimagine the chemistry set for the 21st century.” In the contest materials, the two groups cite the absence of chemistry sets on the market today that inspire creativity.

As the parent of two boys I have to agree. Chemistry toys these days come with prepackaged materials and set instructions for how to use them. Sure, I’m not enthusiastic about some of the dangerous chemicals in the kits that inspired an older generation of scientists, but a bit of creativity would be nice.

Prakash took inspiration from a simple music box to design a handheld chemistry set that can be programmed using holes punched in a paper tape. The prize came from the set’s use as a toy to inspire kids, but Prakash and graduate student George Korir also envision it being used to carry out science in developing countries. They say it can be built for about $5. Prakash told me, “I’d started thinking about this connection between science education and global health. The things that you make for kids to explore science [are] also exactly the kind of things that you need in the field because they need to be robust and they need to be highly versatile.”

My Stanford Report story goes on to describe how it works:

Like the music box, the prototype includes a hand cranked wheel and paper tape with periodic holes punched by the user. When a pin encounters a hole in the tape it flips and activates a pump that releases a single drop from a channel. In the simplest design, 15 independent pumps, valves and droplet generators can all be controlled simultaneously.

Prakash and Korir didn’t set out to make a kit for kids. Their idea was that a portable, programmable chemistry kit could be used around the world to test water quality, provide affordable medical diagnostic tests, assess soil chemistry for agriculture or as a snake bite venom test kit. It could even be used in modern labs to carry out experiments on a very small scale.

This chemistry set and the Foldscope are both part of what Prakash calls “frugal science.” There’s more about how the device works in the technical paper.

Previously: Stanford bioengineer develops a 50-cent paper microscope and Free DIY microscope kits to citizen scientists with inspiring project ideas
Photo in featured entry box by George Korir

The woman was terrified, as she had just come from the hospital, where she discovered she was HIV-positive. It wasn’t so much the virus she feared, as the reaction from her husband. If he were to find out, he would surely beat her and throw her out of the house.

As predicted, the husband arrived home and seeing his wife in distress, forced her to confess what she had learned. “Either I cut you in two pieces and throw you in the ditch or leave the house,” he yelled, his arm raised in threat.

Fortunately, the wife wasn’t harmed, for the drama was merely that – a work of street theatre designed to break the traditional patterns of domestic violence and HIV in Uganda. The drama is one of the creative strategies being used by the nonprofit Center for Domestic Violence Prevention in Kampala, Uganda to effectively reduce incidents of domestic violence by more than 50 percent in the communities it serves.

In the process, group also aims to reduce the incidence of HIV, which affects 7.2 percent of adults in the East African nation, according to the latest figures from the United Nations Joint Programme on HIV/AIDS.

The organization works by mobilizing local men and women and training them in various interventions, like the street drama, address pervasive problem of violence among intimate partners. According to its figures, 59 percent of women between the ages of 15 and 49 say they have experienced physical or sexual violence by a husband or partner at some point in their lives.

“We are talking about an epidemic,” said Tina Musuya, a social worker and a women’s rights activist who directs the organization.

I was fortunate to see the street theatre program in action during a recent trip to Uganda with the American Jewish World Service, an international development organization that works to end poverty and promote human rights in the developing world. Fifteen of us, all Global Justice Fellows with the organization, visited CEDOVIP’s offices in Kampala and then fanned out to see the group’s work in action in the streets of Kampala one sunny afternoon.

A crowd had already begun to materialize by the time we arrived in one of the city’s poor neighborhoods, where three drummers had lured people from their homes with a lively beat. Two female dancers in colorful red outfits (pictured above) then entertained the crowd, whose curiosity was heightened by the presence of us five white foreigners. By the time the drama began, more than 100 people had gathered in the dirt road – youngsters who tugged at our hands, older women who sat on wooden stools to watch and groups of men who stood on the sidelines, quietly assessing the unfolding drama.

The story begins when the woman returns from the hospital to cry on a neighbor’s shoulder. The husband then arrives and suspects something is up. He falls into a rage on learning the wife’s news, threatening to “break her bones” and ordering her to leave the house. But the wife says she has nowhere to go. Besides, she tells him, she acquired the virus from him.

A narrator, dressed in an orange shirt, periodically freezes the drama, soliciting suggestions from the crowd on what the couple should do. One observer tells the woman to call the police. Another urges bystanders to intervene to help save the situation.

“We have so many instances of violence in our neighborhood,” the narrator concludes, speaking in Luganda while our host translates. “See what happens in violent situations when the woman becomes HIV-positive. Be supportive. Support the victims, but also support the man. Change the behavior. Break the silence.”

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Cervical cancer is the third most common cancer among women worldwide, and Mongolia has one of the highest incidence rates in Eastern Asia. Prevention and early detection programs are essential to counteract its prevalence, especially in developing countries.

However, women encounter barriers to knowledge and access to cervical cancer screening services in Mongolia – a country with low population density. The urban–rural divide, lagging healthcare reform, and cultural differences are cited as core factors leading to lack of awareness and treatment.

To address the rising burden, a national cervical cancer screening program was implemented in August 2012 by Mongolia’s Ministry of Health (MOH) facilitated by a grant from the Millennium Challenge Corporation.

Gendengarjaa Baigalimaa, MD, the 2013-14 Developing Asia Health Policy Fellow at Stanford’s Walter H. Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute, has been evaluating the effects of that program. She serves as a gynecological oncologist at the Mongolian National Cancer Center (NCC). Her early findings show that awareness of cervical cancer has increased, and more women and girls are now getting screened. Gendengarjaa recently talked about her research.

What does your “typical” patient look like at the NCC and how has your work informed your research?

Patients typically arrive at the NCC with an advanced stage of disease – 70 percent of these women have progressive forms of cervical cancer. Of course it is not easy to work with patients who are this far along, especially if we are unable to offer full palliative services. As the only cancer center in the nation, just 10 gynecological oncologists are available to take on the high demand for treatment services. Healthcare providers and policymakers designed the Mongolian Cervical Cancer Program to address the alarming incidence rate. My research analyzes behavioral change before and after the introduction of the national screening program, bearing in mind my experiences with my own patients.

What does the national cervical cancer screening program facilitate?

Before the program was implemented, regular cervical cancer screening did not exist in Mongolia. The program diffused and strengthened primary care screening services (Pap test) as well as prevention programs. Gynecological doctors from the NCC were systematically dispatched to the 338 soums or districts throughout the nation. They trained local doctors and midwives on how to administer the Pap test. The program coordinated two initiatives: a pilot HPV vaccination program for girls aged 11-15 years from four select areas and a Pap test program for women aged 30-60 years. The women and girls who participated are urged to get screened every three years thereafter. Health education campaigns were also broadcast on select television and radio programs targeted at women and girls.

Comparing a survey taken at the program’s outset in 2010 to your survey at the program’s conclusion in 2013, what behavioral changes have been observed?

Our preliminary results have shown increased knowledge about risk factors and screening services. Women in both rural and urban areas are now more informed about cervical cancer risk factors. Awareness of the need for a Pap test increased from 15.3 percent in 2010 to 45.3 percent in 2013. The respondents also reported being more educated about the suggested frequency of visiting a doctor, and the availability of services outside of Ulaanbaatar. Due to increased knowledge, 54.2 percent of the women surveyed confirmed that they had attended cervical screening services.

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Foldscope, the ultra-low-cost paper microscope designed to aid disease diagnosis in developing regions, is back in the news. For a story appearing in today’s San Francisco Chronicle, writer Stephanie Lee talked with Stanford bioengineer Manu Prakash, PhD, and others about the invention:

“Manu Prakash is one of the most creative scientists and engineers and his invention is really original,” wrote Luke Lee, a bioengineering professor at UC Berkeley who works on global health problems, in an e-mail. “His elegant microscope is not only good for global health care, but also it will be a new educational tool to see the world.”

The Foldscope was two years in the making, starting with trips that Prakash and his graduate students took through India, Thailand, Uganda and Nigeria. The team met people who were suffering from infectious diseases but couldn’t afford conventional microscopes, which cost upward of $200, to diagnose their conditions.

“It was very clear that anything we came up with, if we can’t scale it to the cost it needs to be, it doesn’t really reach anywhere,” Prakash said.

Prakash went on to tell Lee, “This is not just an academic project. We happen to be in an academic setting, but we are trying to reach society in a very strong way.”

Previously: Free DIY microscope kits to citizen scientists with inspiring project ideas, Stanford bioengineer develops a 50-cent paper microscope, Stanford microscope inventor featured on TED Talk, Stanford bioengineer developing an “Electric Band-Aid Worm Test and Stanford bioengineers create an ultra-low-cost oral cancer screening tool
Photo by James Duncan Davidson/TED

We step across a sewage channel to enter an unmarked, tin-roof building, leaving the bright sunlight for the dark corridors of a 23-room inn in a busy commercial district in Kampala, Uganda. More than a dozen women huddle on the mud floor in a small rectangular courtyard whose walls are charcoal-black. We gradually come to realize that we’ve arrived at a brothel, the destination for our field tour with the Women’s Organization Network for Human Rights Advocacy, a prominent group that fights for the rights of Uganda’s sex workers.

One woman in her 30s, dressed in a black head scarf, does much of the talking for the women at the brothel, speaking in her native Luganda while the manager of the inn translates. The woman says she lost her husband and had no source of income to support herself and her children. “I almost committed suicide,” she says, but a friend encouraged her to try sex work to earn money. “My friend said, ‘I will show you what to do.’” Behind her, three wooden doors lead to squalid, closet-sized rooms where the women live and work their trade.

The women, we learn, have turned to sex work as a matter of survival. Many have lost husbands or partners on whom they depended for income, and they lack the education or skills to find other jobs that pay a livable wage.

“If they turn away from sex work, how will they feed their children or pay their school fees?” one WONETHA official says.

But the work comes with a price. The women frequently face client abuse, beatings and harassment on the streets, even police brutality – including rape, beatings and extortion – and the ever-present risk of HIV.

“Sex workers are facing a health and human rights crisis in Uganda. Despite this, little is being done to protect the most basic human rights of sex workers,” declares a pink banner at WONETHA’s headquarters in central Kampala.

The largest organization of its kind in East Africa, the group works to provide the women with better access to medical care, legal and social services, job training and freedom from violence and arbitrary arrests.

I met with members of the nonprofit group in February as a Global Justice Fellow with American Jewish World Service, an international development organization that aims to end poverty and promote human rights in the developing world. I was among 15 fellows from the Bay Area who spent nine days in Uganda learning about the work of human rights organizations that advocate for women, girls and the LGBT community.

One of WONETHA’s goals is helping prevent HIV among the sex workers and obtain access to medical care for those who are infected with the virus. Sex workers are the greatest at-risk group in the country, with an infection rate of 37 percent in 2010, according to the Uganda AIDS Commission.  At the national level, Uganda was particularly hard-hit by AIDS early on, with the disease reaching epidemic proportions in the 1980s. Between 1992 and 2000, however, there was a dramatic decline in incidence – from an estimated high of about 18.5 percent to 5 percent. In recent years, the number of infections has begun to rise again in what many see as a disturbing trend; the infection rate reached 7.2 percent in 2012, according to the United Nations Joint Programme on HIV/AIDS.  Lax attitudes regarding safe sex and a lack of condom use are among the factors cited in the trend.

WONETHA distributes condoms to help protect sex workers against HIV and other sexually transmitted diseases. A dozen large boxes of Chinese-made condoms, supplied by the United Nations Population Fund, occupied a cool space in the group’s headquarters on the day of our visit – some 100,000 of them ready to be distributed to various locations around town.

But condom use, we are told, is not always guaranteed. Clients may resist using them or pay more for a condom-free encounter. A program manager with the group told me that even in marriages, many men resist use of condoms but continue to have multiple partners – putting their wives and the other partners at risk.

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